Triple Curvature Adult Idiopathic Scoliosis treated by Robert Pashman MD: Case 21

Case Review #21: Triple Curvature Adult Idiopathic Scoliosis from Robert Pashman

A 23 year old male presented with a triple adult idiopathic scoliosis curvature. The curvature progressed despite bracing. Dr. Pashman performed a spinal fusion from T4-L3.

Case Review:

Triple Curvature Adult Idiopathic Scoliosis, treated with a posterior spinal fusion, T4 to L3

Patient History:

23-year-old male
Progressive Adult/Adolescent Idiopathic Scoliosis
The curve progressed despite the patient’s compliance with wearing the brace as a child.
The curves measured Cobb angle, thoracic-thoracic-lumbar,at 36/58/44, and the 58-degree thoracic curve is rigid.
This is classified as a triple major curve by side bending or a 4Ccurve.

Pre-op X-rays:

Clinically, the patient had a right rib hump and significant left lumbar fullness, which indicated structurality and significant rotation of the lumbar component, deeming this a triple major curve. Although the shoulders are somewhat level, the proximal curve could be mobilized through the proximal thoracic segments. The patient has a cervical rib and lumbosacral transitional vertebra, and the count was adequately matched with the intraoperative observation of the curve angles.

Indications for Surgery:

Type 6 triple major adult/idiopathic progressive scoliosis; type 4C curve.
Rigid deformity with increasing pain in thoracic and lumbar spine.
Sagittal and coronal plane decompensation with highly rotated, rigid scoliosis.
Failure to be treated conservatively with adolescent bracing.

Surgical Strategy:

1. Segmental spinal instrumentation, thoracic-4 to lumbar-3, using  5.5 stainless steel pedicle screw-rod construct.
2. Posterior spinal fusion, T4 to L3, using locally harvested autogenous bone and recombinant human bone morphogenetic protein.
3. Mobilization of rigid thoracic and lumbar curve through spinal osteotomies, T5 to T11 (these are Smith-Petersen osteotomies), and mobilization with radical facetectomy and osteotomy of lumbar spine, L1 to L3.
4. Interlaminar decompression for visualization of medial pedicle, L3.
5. Intraoperative somatosensory evoked potential and motor evoked potential management.
6. Intraoperative fluoroscopy management.

Post-Op Films:

A 38° correction was obtained. The patient is well balanced in both the sagittal and coronal planes.

Pre-Op/Post-op Comparison:

The patient had an excellent 44° outcome. His shoulders and hips are level, his rib hump decreased. From a clinical standpoint, he is well balanced in both the frontal and sagittal planes.

Related links:

Scoliosis overview
Adult Idiopathic Scoliosis
Patient journal of scoliosis surgery, Patient follow-up journal four years after surgery
Scoliosis FAQ’s
Books about Scoliosis